A 33-year-old male presented to our clinics after failing the driver’s license vision examination. The patient reported noticing poor vision in his left eye 6 months ago. This was his first eye exam. His health was unremarkable and he was on no medications. The patient denied flashes and floaters.

Entrance VAs were as followed:

OD: 20/20

OS: 20/400 Pinhole: No improvement.

EOM were WNL, visual field was FTFC OD and had a defect supero-nasally OS. The left eye had a + APD.

The anterior segment was WNL OU however the left eye had a positive Schaffer sign, which was odd considering the fact that the patient denied seeing floaters…

The fundus evaluation of the right eye was WNL, see below for the left eye:

This fundus photo shows an area of disinsertion of the retina from the ora serrata inferotemporal with associated retinal detachment. By looking carefully, we can notice that the detachment is separated in 2 parts; A first detachment that goes up until the mid periphery that seem to be chronic in nature due to 1) the fibrotic changes observable below the detachment (white arrow) (see image below) and 2) the pigmentary demarcation line (red arrows). This pigmentary demarcation line indicates that the detachment most likely held stable for a while; however, as this picture shows, the detachment eventually progressed to the macular area which is detached as well now (black arrows). Unfortunately, this patient seemed to have a macular hole as well.

Upon further questioning, the patient recalled a remote history of a fight 1.5 years ago in which he received multiple punches to the face. The patient never experienced flashes of light or floaters.

We diagnosed our patient with chronic retinal dialysis and associated retinal detachment of the left eye.

Discussion

Retinal dialysis is a specific type of retinal tear that occurs at the junction between the retina and the ciliary body known as the ora serrata. It is commonly associated with a history of ocular trauma, especially blunt injury with fists.

Retinal dialysis is most commonly seen in men around the age of 28 years old. It is most often unilateral and has a higher prevalence to be found in the inferotemporal quadrant as this is the weakest part of the peripheral retina and also because this part of the eye is more exposed anatomically.

Pathophysiology

In retinal dialysis, the retina is circumferentially separated from the pars plana at the ora serrata. Blunt trauma induces this type of retinal break by swiftly compressing the eye along its front-to-back axis and expanding it horizontally, thereby creating tension near the ora serrata leading to the tear.

Sign and symptoms

Many patients are initially asymptomatic and do not present for examination until the dialysis has become a detachment. A retrospective review by Zion, et al. showed that only 15.8% of cases of retinal dialysis manifested within one month of injury, while 41% were diagnosed more than one year after the injury [1]. Another study showed that only 58% of patients with a retinal detachment secondary to a traumatic retinal dialysis were symptomatic [2].

It is postulated that the lack of symptoms is attributed to several factors: retinal dialysis often occurs without concurrent posterior vitreous detachment, subretinal fluid accumulates gradually, and superior visual field loss is not noted initially.

When symptoms are present, they may include flashes of light, floaters, loss of visual field and blurred vision. In a study involving 196 patients with retinal dialysis, the most common presenting symptoms was blurry vision secondary to macular detachment [1].

This common lack of symptoms highlights the importance of careful scleral depressed examination following trauma to the face especially to the eye.

Imaging

In case of media opacity or vitreous hemorrhage, a B-scan is recommended to identify potential detachment and even tears sometimes. Ultra-wide field imaging such as Optomap has also shown to be very useful in the assessment of the peripheral retina.

Management

Overall, a retinal dialysis should be approached similarly to a classic peripheral retinal tear; in the absence of subretinal fluid, photocoagulation or cryopexy are good treatment options [3]. In the case of subsequent retinal detachment, treatment should be initiated in the same time period as a rhegmatogenous retinal detachment; within 24 hours for at-risk macula-on detachments and between a few days to 1 week if it is a peripheral detachment that does not show risks of imminent progression [4].

Studies have shown that Scleral buckling is the most successful initial treatment in patients with retinal detachment associated with retinal dialysis (87-95% success rate) [5, 6, 7]. Considering the young age at which dialysis occurs in these patients (≈ 28 years old), scleral buckling is an ideal treatment because it helps prevent posterior vitreous detachment and secondary procedures such as cataract extraction so these patients can maintain their normal accommodation.

Back to our patient

Our patient reported a remote history of a fight 1.5 years ago in which he was punched multiple times in the face. This punctual traumatic event allows us to assume that the dialysis started that day. However due to the lack of visual symptoms, the patient did not go for an eye exam and his retina most likely started detaching. As the pigmentary demarcation line shows, the detachment stopped midway for some time however, it eventually progressed further and led to a macula-off retinal detachment causing the blurry vision. The patient underwent surgical repair and the retina was reattached however, due to delayed treatment timing (6 months since macular detachment) visual acuity only improved from 20/400 to 20/200.

Note: If our patient would have presented to clinics shortly after his traumatic injuries, vision loss could have most likely been avoided with simple laser retinopexy or cryopexy to prevent extensive retinal detachment.

Summary

In summary, Retinal Dialysis is a desinsertion of the retina at the ora serrata and affects male more than females (2:1 ratio) at an average age of 28 years old. It is most commonly due to ocular injury especially blunt trauma with fists and is predominantly unilateral. Most common location is inferotemporal. Patients are often asymptomatic until macular detachment occurs, however symptoms may include flashes, floaters, visual field loss or decreased visual acuity. A thorough scleral depressed examination should be performed on every patient following ocular/facial trauma to rule out retinal dialysis as many might be asymptomatic. Laser photocoagulation/cryopexy are good treatment options for dialysis without detachment. In case of subsequent detachment, scleral buckling is the best treatment option.

References

  1. Zion VM, Burton TC. Retinal dialysis. Arch Ophthalmol 1980;98(11):1971-1974.  https://PubMed.gov/7436828
  2. Ross WH. Traumatic retinal dialyses. Arch Ophthalmol 1981;99(8):1371-1374.  https://PubMed.gov/7259608
  3. Schachat AW, Charles; Hinton, David; Sadda, SriniVas; Wiedemann, Peter. Ryan’s Retina. Sixth ed. China: Elsevier, 2018.
  4. The repair of rhegmatogenous retinal detachments. American Academy of Ophthalmology. Ophthalmology 1996;103(8):1313-1324.  https://PubMed.gov/8764804
  5. Ross WH. Traumatic retinal dialyses. Arch Ophthalmol 1981;99(8):1371-1374.  https://PubMed.gov/7259608
  6. Jan S, Hussain Z, Khan U, Khan MT, Karim S. Retinal Detachment Due to Retinal Dialysis: Surgical Outcome After Scleral Buckling. Asia Pac J Ophthalmol (Phila) 2015;4(5):259-262.  https://PubMed.gov/26431208. DOI: 10.1097/APO.0000000000000084
  7. Chang JS, Marra K, Flynn HW, Jr., Berrocal AM, Arroyo JG. Scleral Buckling in the Treatment of Retinal Detachment Due to Retinal Dialysis. Ophthalmic Surg Lasers Imaging Retina 2016;47(4):336-340.  https://PubMed.gov/27065373. DOI: 10.3928/23258160-20160324-06